The 660-page opioid bill that passed Congress and was signed October 24 by President Trump has important provisions for opioid treatment programs (OTPs). The most significant provision expands coverage to Medicare patients. Starting in 2020, Medicare will be required to pay a bundled rate for medication-assisted treatment (MAT) in an OTP. This means that when patients turn 65 and lose their Medicaid or commercial insurance, getting Medicare instead, they will be able to stay in treatment.

Other aspects of H.R. 6, also called “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act,’’ or the ‘‘SUPPORT for Patients and Communities Act,” have ramifications for OTPs as well (see below).

Opening the Door to Medicare for OTP Patients

The OTP Consortium has expressed its support for this measure since last February, when Rep. George Holding (R-North Carolina) first put forward the measure under House Resolution 5080, the Comprehensive Opioid Management and Bundled Addiction Treatment (COMBAT) Act of 2018. “Congressman Holding’s legislation opens the door to patient access for a vulnerable Medicare population that currently lacks coverage for Opioid Use Disorder (OUD) treatment provided by OTPs. I commend Congressman Holding and his colleagues for crafting a bill that will certainly improve our nation’s response to the opioid crisis by filling this treatment gap and assisting this population on their Road to Recovery,” stated Peter Morris, Group President of Acadia Healthcare.

That measure became incorporated into H.R. 6.

A Major Victory

“The bill is a major victory for patients who are Medicare eligible and who are about to be eligible,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD). “CMS Medicare will construct the rate, and I expect it to be a weekly bundled rate, which will include all three federally approved medications, in addition to lab testing and clinical services,” he told AT Forum. “For the present time, I will be informing programs about how to prepare, and will develop a webinar in order to provide technical assistance.”

The bill “is an extraordinary opportunity for patients, and I do not see any part that is a threat to treatment,” said Mr. Parrino.

“We are extremely pleased that Congress has included Medicare coverage of OTPs in the just-passed opioid package,” said Jason Kletter, PhD, president of BayMark Health Services. “This coverage will, once implemented, provide immediate benefit to the roughly 20,000 Medicare beneficiaries currently receiving treatment in OTPs, as well as create treatment access for the 300,000 beneficiaries with a diagnosis of opioid use disorder,” Dr. Kletter told AT Forum. “In addition, Medicare coverage will likely result in greater coverage of OTP services by commercial health plans, exponentially increasing access to high quality, evidence-based MAT across the country.”

The Need is Clear, and Methadone Works

OTPs provide not only medications—methadone, buprenorphine, and naltrexone—but support services, which may include counseling, toxicology screening and lab services, case management, primary care, and mental health services.

The FDA-approved medication methadone, as part of a MAT program, has been recommended by the National institutes of Health as the most effective treatment option for OUD. OTPs provide medically supervised access to this medication as well as buprenorphine and naltrexone, along with support services.

Medicare beneficiaries show a clear need for OUD treatment: 300,000 beneficiaries have been diagnosed with OUD, Medicare hospitalizations due to complications of opioid misuse increased 10% a year, and 30% of Medicare Part D enrollees used prescription opioids in 2015.

Success—After 10 Years’ Work

It has taken Mark Parrino more than 10 years to get this legislation passed. It was impossible for the Centers for Medicare and Medicaid Services to make the change on its own: Congress needed to act in order to approve the bundled rate. The Senate side had proposed a demonstration project, which would have covered a fraction of Medicare patients at greater cost.

According to the Congressional Budget Office, the full Medicare benefit will cost $243 million, which, if it covers all 300,000 Medicare beneficiaries with an OUD, would cost $810 per person.

The Medicare provision is Section 2005 of H.R. 6.

Now, it’s up to OTPs to gear up to bill Medicare, once CMS sets the bundling rate and codes.

From the bill, below are the Medicare provisions for OTPs:

All opioid agonist and antagonist treatment medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration for use in the treatment of opioid use disorder would be covered, including dispensing and administration.

Counseling, including individual and group therapy, for substance use would be covered to the extent authorized by state law.

Toxicology testing would be covered.

Medicare will pay OTPs an amount which is equal to 100% of a bundled payment for OUD treatment services, starting January 1, 2020.

Other aspects of the bill with relevance to OTPs:

Demonstration project to increase substance use provider capacity under the Medicaid program.

Guidance to improve care for infants with neonatal abstinence syndrome and their mothers; GAO study on gaps in Medicaid coverage for pregnant and postpartum women with substance use disorder.

Medicaid health homes for substance-use-disorder Medicaid enrollees.

More flexibility with respect to medication-assisted treatment for opioid use disorders.

Medication-assisted treatment for recovery from substance use disorder.

Grants to enhance access to substance use disorder treatment.

Access expansion under the Medicare program to addiction treatment in Federally Qualified Health Centers and rural health clinics.

Review required of quality measures relating to opioids and opioid use disorder treatments furnished under the Medicare program and other federal health care programs.

Report on addressing maternal and infant health in the opioid crisis.

Comprehensive opioid recovery centers , which would provide inpatient and outpatient treatment with all FDA-approved medications, including methadone.

“President Donald Trump signed a landmark bill Wednesday intended to deal with the nation’s opioid epidemic, a bipartisan breakthrough for a crisis claiming tens of thousands of U.S. lives every year.

Congress approved the Support for Patients and Community Act with wide bipartisan margins. Though advocacy groups have applauded the legislation, some have questioned its impact unless lawmakers approve billions more for treatment.”

A look at five major provisions of the legislation Trump signed into law:

The bipartisan opioid bill was approved by the Senate and House of Representatives conferees, and is now headed for a full vote in the House. There is much good news: Confidentiality under 42 CFR Part 2 is still protected, and Medicare will cover treatment for all in an OTP (opioid treatment program) with methadone as well as with other approved medications.

42 CFR Part 2

Under the House version, 42 CFR Part 2 would have been replaced by HIPAA, severely limiting patients’ rights to control access to their medical records. Last week the American Medical Association wrote lawmakers, urging them to protect 42 CFR Part 2, saying that without it, patients would hesitate to seek treatment (as the American Association for the Treatment of Opioid Dependence, as well as coalitions of patients, and the Legal Action Center, have said repeatedly).

Medicare

The House version of the opioid bill would provide for complete coverage by Medicare for patients in OTPs, so they would not have to drop out of treatment─or pay for it on their own─once they turn 65. That is how the final bill reads, as well. The Senate version, however, would have provided for only a five-year pilot project.

Next Steps

On September 25 the House of Representatives Ways and Means Committee conferees released the text of H.R. 6 (https://docs.house.gov/billsthisweek/20180924/HR6.pdf). Next, the full House must vote on the bill, which could take place this week. There could still be changes, at the last minute, if major mistakes are found.

Still, these two measures were watched closely by OTP advocates, as the opioid legislation went through Congress.

“Great news: thanks to our collective efforts, the final negotiated opioid package came out of Congress today, including our Medicare policy!” said Jason Kletter, PhD, AATOD legislative committee chair, in a September 26 statement. “This is great news, as it will not only provide a new funding source for our patients, but will also lead to more commercial insurers covering OTP services, given Medicare is a benchmark plan followed by many private carriers.”

“A new study that puts an astronomical price tag on a Medicare-for-all proposal has prompted mockery from conservatives and defensive cries from liberals.

The analysis, from the libertarian-leaning Mercatus Center at George Mason University, focuses on legislation introduced by Sen. Bernie Sanders (I-Vt.) and estimates that his proposal to create a national health insurance system would lead to a $32.6 trillion increase in federal spending over a 10-year period.

The eye-popping figure is tied in large part to the fact that under Medicare for all, the federal government is designed to take on almost all health spending. Which explains why federal spending would go up significantly.

Proponents of Medicare for all, also known as a single-payer system, are quick to note the study also estimates national expenditures on health care would decrease by about $2 trillion by 2031 if the Sanders bill were signed into law.

That means overall health-care spending would decline, but the government’s share of that figure would go up, something small-government Republicans find unsettling.”

“Legislation to address the opioid epidemic is advancing in both the House and Senate. The House has passed several bills related to Medicaid and opioids, culminating in the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.

The Senate Finance Committee has advanced the Helping to End Addiction and Lessen (HEAL) Substance Use Disorders Act, which is expected to be considered by the full Senate later this year. Both the SUPPORT Act and the HEAL Act contain a number of provisions related to Medicaid’s role in helping states provide coverage and services to people who need substance use disorder (SUD) treatment, in addition to Medicare and other health-related provisions. This issue brief summarizes current federal legislative proposals related to Medicaid’s role in the opioid epidemic and identifies issues to watch as final legislation takes shape.”

In May, two important bills which would expand Medicare coverage to include Opioid Treatment Programs (OTPs) were put forward. H.R. 5776, the Medicare and Opioid Safe Treatment Act, and S 2875, the Comprehensive Opioid Management and Bundled Addiction Treatment Act, were introduced.

It’s up to Congress to fix the problem: Medicare Part B does not cover treatment in an OTP. This means that when patients turn 65, and are eligible for Medicare, they have no way to pay for treatment.

Advocates for Opioid Recovery is urging everyone to contact their members of Congress to support these bills.

“Recently, U.S. Senators Rob Portman (R-OH) and Bob Casey (D-PA) introduced the Medicare Beneficiary Opioid Addiction Treatment Act (S. 2704), legislation that would break down existing barriers to treatment, by providing coverage for methadone under Medicare Part B and allowing seniors and people with disabilities to receive this important medication in their doctor’s office.

Opioid use disorder is a growing problem among older adults and people with disabilities, as nearly 12 million people with Medicare were prescribed opioids in 2015. In fact, the President’s FY2019 budget request proposes to test and expand Medicare treatment options, including reimbursing for methadone.

The bill is supported by the American Medical Association, the Center for Medicare Advocacy, Medicare Rights Center, National Committee to Preserve Social Security and Medicare, and the Alliance for Retired Americans.”

“A House panel advanced a series of opioid bills Wednesday that would link overdose victims to treatment before leaving the emergency room, let hospice workers get rid of unused pills and spur the National Institutes of Health to find non-addictive solutions for pain.

All told, the Energy and Commerce Committee approved 25 bills aimed at reining in the addiction crisis that’s killing tens of thousands of Americans per year.

If enacted into the law, the measures would expand the use of “mail-back pouches” to destroy unused pain medication and help the Centers for Disease Control and Prevention combat rates of HIV/AIDS, Hepatitis C and other diseases tied to intravenous drug use.

Patients covered by Medicare would see changes, too. Doctors would have to transmit prescriptions for potentially addictive drugs electronically — to reduce the number of fraudulent or manipulated scripts — and enrollees would learn about the potential dangers of using opioids.”

“One in three older Americans with Medicare drug coverage is prescribed opioid painkillers, but for those who develop a dangerous addiction there is one treatment Medicare won’t cover: methadone.

Federal money is flowing to states to open new methadone clinics through the 21st Century Cures Act, but despite the nation’s deepening opioid crisis, the Medicare drug program for the elderly covers methadone only when prescribed for pain.

Methadone doesn’t meet the requirement of Medicare’s Part D drug program because it can’t be dispensed in a retail pharmacy.

In Congress, legislation has been introduced in the House and Senate, and a White House commission on the opioid epidemic also recommended the change.”

“As we highlighted earlier this month, CMS released both the Contract Year 2019 Final Rules for Medicare Advantage and Part D (Final Rules) and the 2019 Call Letter. These documents are not typically released at the same time, so there is a lot of information for Medicare Advantage organizations and Part D plan sponsors to absorb. One major topic area that CMS focuses on in these documents is the prevention of opioid misuse and abuse.

The Final Rules and 2019 Call Letter work together to establish a number of new policies aimed at helping Medicare plan sponsors prevent and combat prescription opioid overuse. There is significant discussion, including CMS’s response to commenters, in the final documents linked above. Here, we provide a high-level overview of the new policies.”